Laparoscopic Sleeve Gastrectomy T Sammour, AG Hill, P Singh, A Ranasinghe R Babor, H Rahman

Obesity in NZ In NZ: 1 in 4 adults are obese (2007 MOH survey => 26.5%; CI 25.5 – 27.5) cf Australia “obesity epidemic” in 2001 => 17% of adults obese Obesity picture worse in South Auckland… Lower socioeconomic group High proportion of Maori and Pacific Islanders

Obesity surgery Offered at CMDHB since March 2007 2 Surgeons and nurse specialist MDT input Dietician Endocrinologist Anaesthetist Lap sleeve gastrectomy procedure of choice

Sleeve Gastrectomy Technique 4 port laparoscopy 36F boogie 4cm from pylorus Selective re-inforcement Air leak test Bands no funding or clinic resources for rechecks, minor complication surgery Wt loss not as good, and similar complication rate overall.

Criteria for Surgery European consensus guidelines * Must 20 – 65 years old BMI > 40, or ≥ 35 with comorbidities Must quit smoking establish regular exercise program lose atleast 0.5kg / week between appointments maintain 3 weeks of Optifast diet pre-operatively Approx 10kg wt loss expected preop * Fried et al. Interdisciplinary European guidelines on surgery of severe obesity. Obesity Facts 2008;1:52–58.

Audit Retrospective review of the first 100 patients at Counties Manukau DHB March 2007 – August 2008 Data collected: Demographics Pre-op weight / BMI Comorbidities (defined by treatment) Operative variables Complications / mortality Weight Loss Resolution of obesity-related comorbidities Patient satisfaction score

Patients Mean age 42.7 years (20 – 60) Sex Ethnicity Male 20% Female 80% Ethnicity European 60% Maori 19% PI 12% Mean weight 140.7 kg (96.7 – 211.9) Mean BMI 50.2 kg/m2 (36.0 – 73.0) 45 patients super-obese by definition

Medical Comorbidities Diabetic 25% All but one patient type II 20% on insulin HTN on medication 45% Hyperlipidaemic on medication 25% OSA on CPAP 17% Other Cardiovascular 8%

Results Median hospital stay 2 days (1 – 7) Mean follow-up 12.0 months (0.9 – 23.3) Mean weight loss 40.9 kg (4.4 – 78.2) Median satisfaction 10 (3 – 10) Mean excess wt loss 63.2% (7.2 – 129)

Comorbidity Resolution Diabetes 48.0% stopped medication 24.0% reduced medication Hypertension 35.6% stopped medication 24.4% reduced medication Hyperlipidemia 5 of 25 stopped medication OSA 9 of 17 came off CPAP

Operative morbidity Mortality 0% Major complication 8.0% 1 iatrogenic transected stomach => converted to open 3 staple line leaks 1 requiring laparotomy and suture of pinhole leak 1 stented (distal stricture) 1 normal diag lap on D3, CT leak collection on D22 => perc drain 2 staple line bleeds 1 requiring laparotomy 1 re-laparoscopy and application of surgicell 1 infected haematoma requiring laparotomy 1 critical stricture requiring endoscopic dilation

Operative morbidity Minor complication 2.0% Other readmit 6.0% 1 patient had normal diagnostic lap for presumed bleed 1 umbilical hernia requiring open mesh repar No port site wound infections No DVT / PE Other readmit 6.0% 4 readmit for pain / vomiting 1 constipation requiring enema 1 leg pain and swelling => USS no DVT

Conclusion Laparoscopic sleeve gastrectomy has achieved satisfactory weight-loss results, with > 60% excess weight loss in the medium term. Acceptable complication rate. Long term weight loss results are awaited.

Largest (of two) published RCT A Prospective Randomized Study Between Laparoscopic Gastric Banding and Laparoscopic Isolated Sleeve Gastrectomy: Results after 1 and 3 Years Jacques Himpens, MD; Giovanni Dapri, MD; Guy Bernard Cadière,MD, PhD Department of Gastrointestinal and Obesity Surgery Saint-Pierre University Hospital, Brussels, Belgium Obesity Surgery 2006, 16, 1450-1456 Largest (of two) published RCT 80 patients mean BMI 38 % Excess wt loss at 1yr Band 41.4% Sleeve 57.7 % (p = 0.0004) % Excess wt loss at 3yrs Band 48.0% Sleeve 66.0 % (p = 0.0025)

Complications

% Excess wt loss at 6 months 1st published RCT 20 patients mean BMI 47.5 No post-op complications in either group % Excess wt loss at 6 months Band 28.7% Sleeve 61.4% (p = 0.001)

Ghrelin Band (n = 10) Sleeve (n = 10) Day 1: No change in plasma ghrelin 1 month: Significant increase 6 months: Significant increase Sleeve (n = 10) Day 1: Significant decrease 1 month: Remained stable (low) 6 months: Remained stable (low) Ghrelin is the only consistently reported hunger regulating hormone, produced in the fundus of the stomach. Significantly increased in diet induced weight loss. In fact, consistent with 5 other studies showing either no change or increase in levels post banding.

ASERNIP 2002 - bands Level of evidence: Average (up to 4 years follow-up). Safety: Banding lower short term mortality than VBG and gastric bypass Not enough long term and morbidity data. Efficacy: Banding is as effective, up to 4 years. Not enough long term data. Recommendations: Long-term efficacy of gastric banding remains unproven and further evaluation is recommended.

Adelaide 600 bands, 7 years follow-up Preop BMI 43 25.7% complication rate (10.4% perioperative, 15.3% on long term).